Pain is a clinical challenge for many cancer patients and physicians, and according to Heather Greenlee, ND, PhD., there is growing evidence that integrative therapies can be helpful in pain management.
A new joint practice guideline from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) used 227 relevant studies to provide evidence-based recommendations about integrative medicine approaches to pain management in cancer patients.1
Directive published in Journal of Clinical Oncology, gives a moderate strength of recommendation for the use of acupuncture for aromatase inhibitor-related joint pain and may recommend it, along with reflexology or acupressure, for general cancer pain or musculoskeletal pain. Additionally, hypnosis may be recommended for patients who experience procedural pain, and massage is recommended for patients who experience pain during their palliative or hospice care.
According to the joint panel, the recommendations were based on a moderate level of evidence, but the benefits of the procedures outweighed the risks to patients. However, they found that the evidence for mind-body interventions or natural products such as yoga, omega-3 fatty acids, music therapy, or topical pure emu oil was insufficient to recommend for or against these interventions. Additionally, they did not have enough evidence to recommend pain interventions for pediatric cancer patients.
“Pain is a clinical challenge for many oncology patients and physicians, and there is increasing evidence that integrative therapies can be useful in pain management. But to date, there is no clear clinical guidance on when and when not to use these approaches,” said Heather Greenlee, ND, PhD, co-chair of the SIO Clinical Practice Guideline Committee, in an SIO press release.2
An international multidisciplinary panel of experts, including patient representatives and health research methodology, was formed between the two groups to develop this practice guideline. Recommendations were then developed using a systematic review of 1,346 articles from PubMed (1990-2021) and the Cochrane Library (1990-2021) focusing on whether the study population included adult and pediatric patients experiencing pain at any stage of their cancer care. trajectory; integrative interventions that included acupuncture, acupressure, mind-body therapies, and natural products; no within-exam comparisons; outcomes that included pain intensity, reduction, or change in symptoms reported as the primary outcome in the manuscript.
After reviewing the articles against the criteria, 227 articles remained to form the basis for guideline recommendations. While the panel noted that many of the primary studies included in the review suffered from flaws and limitations in their study design. Therefore, they used systematic reviews to identify relevant primary studies. Other weaknesses included lack of blinding in the study design, unmatched control arms, small sample sizes and/or high attrition rates, and limited statistical power, which reduced confidence in the findings for some interventions.
Acupuncture was the most identified intervention in 51 articles compared to massage in 14 articles. In patients with generalized cancer pain or musculoskeletal pain, one study randomized 360 patients in a 2:1:1 ratio to receive electroacupuncture, auricular acupuncture, or usual care. Electroacupuncture reduced pain by 1.9 points on a 0-10 numerical pain rating scale, and auricular acupuncture reduced pain by 1.6 points compared to usual care. These results were also sustained at 6 months and were associated with minimal toxicity, so the panel recommended these interventions for patients with general cancer pain.
“Practice guidelines are a critical way to ensure that health care providers are using treatments that are based on high-quality evidence from scientific studies that have shown treatments to be effective and safe,” said the immediate past chair of ASCO’s Evidence-Based Medicine Committee, Scott T. Tagawa, MD, MS, in a press release. “The guidelines address important issues in patient care that significantly impact quality of life and will help equip the oncology community with the essential knowledge needed to guide integrative therapeutic approaches.”
Integrative oncology is a patient-centered, evidence-informed field of cancer care that uses pain interventions such as mind-body practices, natural products, and lifestyle modifications from various traditions in addition to conventional treatments. With such a wide field, the panel feels the need to provide evidence-based recommendations to enable oncology professionals to make informed decisions.
They also note within the guidelines that the guidelines exist within a healthcare setting that has disparities between patient groups and note that many patients may have limited access to medical care. For example, race and ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location of residence, immigrant status, and access to insurance affect how many integrative patients they can accept. The panel therefore recommends working on these interventions in patient care and removing structural barriers to care.
“This is the first of 3 evidence-based guidelines for adults that SIO and ASCO are jointly developing, combining the strengths of the two organizations,” added Linda E. Carlson, PhD, SIO president, in a news release. “The goal of this important collaboration is to inform as many clinicians and patients as possible about where the evidence lies for integrative therapies to promote the best possible clinical outcomes for all cancer patients. And we believe this new directive will achieve that.”
1. Mao J, Ismaila N, Bao T, et al. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology – ASCO Guideline. J Clin Oncol. 19 September 2022. doi: 10.1200/JCO.22.01357
2. New SIO/ASCO Pain Guidelines Released. Hanna Hayden. September 19, 2022. Accessed: September 22, 2022. https://bit.ly/3C7I8N7
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